Arthroscopic versus open irrigation and debridement in native knee septic arthritis: A retrospective review.

Introduction: Native knee septic arthritis is a rare condition with a potential for high morbidity if not promptly treated. Treatment involves surgical decompression of the affected joint along with systemic antibiotic therapy. The purpose of this study is to compare arthroscopic versus open irrigation and debridement for treatment of native knee septic arthritis. Methods: A retrospective review was conducted at a single academic institution of all patients treated for native knee septic arthritis from January 2007 until August 2018 utilizing ICD and CPT codes. Patient demographics, type of surgical procedure, need for reoperation, laboratory values, length of stay, and comorbidities were compared. Results: A cohort of sixty-six patients who underwent 85 surgeries were included. Among these surgeries, 52 (61%) were arthroscopic while 33 (39%) were open arthrotomies, and 21% required more than one operation. While not statistically significant, the odds of reoperation was higher for those that underwent arthroscopic compared to open irrigation and debridement on univariable (OR = 4.05, p = .08) and multivariable analysis (OR = 4.39, p = .10). Additionally, patients were more likely to require a longer hospital stay if they initially underwent arthroscopic rather than open debridement (RR = 1.31, p = .02). Conclusion: Native knee septic arthritis can be treated with a single surgery in the majority of cases. In our sample, there was an increased odds of reoperation in those treated arthroscopically compared to open, though this finding was not statistically significant. We found longer length of stay for patients undergoing arthroscopic rather than open irrigation and debridement - even after controlling for multiple operations, culture status, sex, age, and comorbidities.

The Effect of Obesity on Pediatric Tibia Fractures.

Background: Childhood obesity affects nearly one fifth of all children in the United States. Understanding the unique injury characteristics and treatment of tibia fractures in this population has become increasingly important. This study aims to explore the different injury characteristics between tibia fractures in obese and non-obese children. Methods: 215 skeletally immature children aged 2-18 who sustained tibia fractures between 2007.2019 were retrospectively reviewed. Patients were analyzed by weight group: underweight, normal weight, overweight, and obese as defined by body mass index (BMI) percentile based upon age. Analyses were performed on dichotomized groups: underweight and normal weight versus overweight and obese. Chi-square or Fisher's exact test was used to compare differences in categorical outcome between the 2-category BMI class variables; Wilcoxon test was used to compare continuous outcomes. A multivariate logistic regression model was used to evaluate BMI associations while controlling for age, sex, race, and mechanism of injury. Results: Distribution of BMI in the cohort included 6.5% underweight, 45.6% normal weight, 16.7% overweight and 31.2% obese. Overweight and obese children sustained fractures from low energy mechanisms at more than double the rate of normal and underweight children (20.5% versus 9.7%, p=0.028). Overweight and obese children sustained physeal fractures at a rate of 54.4% in comparison with 28.6% in their normal and underweight peers (p<0.0001, OR 2.50 (95% CI, 1.26-4.95)). Overweight and obese children sustained distal 1/3 tibia fractures at a higher rate of 56.9% compared to under and normal weight children at 33.9% (p=0.003, OR 2.24 (95% CI, 1.17-4.30)). Overweight and obese children underwent unplanned changes in treatment at a lower rate than normal and underweight children at 1% versus 8% rates of treatment change, respectively (p=0.013, OR 0.076 (95%CI, 0.009-0.655)). No significant differences were found in the rates of operative treatment, repeat reduction, post treatment complications, or physical therapy. Conclusion: Overweight children sustain tibia fractures from low energy mechanisms at higher rates than their peers. Similarly, obese and overweight patients have higher rates of physeal injuries and higher rates of distal 1/3 tibia fractures. Complication rates are similar between obese and non-obese children undergoing treatment for tibia fractures. Level of Evidence: III.

Quality of Life Improvement Following Reconstruction of Midtarsal Charcot Foot Deformity: A Five Year Follow-Up.

Background: There is increasing interest in reconstruction of diabetes-associated Charcot foot arthropathy with the goal of improving quality of life. Methods: Twenty-four patients who completed the Short Musculoskeletal Function Assessment (SMFA) at baseline and one year following Charcot foot reconstruction were contacted and asked to complete the survey at five years following surgery. Results: Fourteen of the 24 patients completed the SMFA preoperatively, one year following surgery and five years postoperatively. Two patients underwent below knee amputation in the interim. Improvement was noted in all domains measured by the SMFA, with a statistically significant improvement in difficulty with daily activities at five years. Conclusion: Correction of non-plantigrade Charcot foot arthropathy results in clinically meaningful improvement in health-related quality of life at both one and five years postoperatively, including independence with daily activities. The improvement is maintained when reevaluated at five years. This supports the modern paradigm shift towards reconstruction of this deformity. Level of Evidence: III.

Epidemiology of Meniscal Allograft Transplantation at Children's Hospitals in the United States.

BACKGROUND: Meniscal allograft transplantation (MAT) was developed with the goal of delaying the progression of degenerative disease in the setting of substantial meniscal deficiency. This may be especially important in children and adolescents; however, there is a paucity of literature on MAT in this population. PURPOSE: To evaluate the epidemiology of MAT at pediatric hospitals in the United States, with specific attention to regional and characteristic trends. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The Pediatric Health Information System, a national database consisting of 49 children's hospitals, was queried for all patients younger than 25 years who underwent MAT between 2011 and 2018. Characteristic information and surgical history were collected for each patient. The database was also queried for all patients who underwent other meniscal surgeries (including debridement, meniscectomy, and meniscal repair) during the same period (controls). Characteristic and geographic data from the control group were compared with those of the patients who underwent MAT. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounding factors. RESULTS: A total of 27,168 meniscal surgeries were performed in 47 hospitals, with MAT performed 67 times in 17 hospitals. Twelve (18%) patients underwent a subsequent procedure after transplantation. In multivariate analysis, each year of increasing age resulted in 1.1 times higher odds of having undergone MAT (95% CI, 1.03-1.1; P = .002) compared with repair or meniscectomy. Patients who underwent MAT also had 2.0 times higher odds of being women (95% CI, 1.2-3.3; P = .01) and 2.0 times higher odds of being privately insured (95% CI, 1.1-3.6; P = .02). MAT was performed most frequently in the Northeast (4.9/1000 meniscal surgeries) and least often in the South (1.1/1000 meniscal surgeries) (P < .001). CONCLUSION: In the United States, pediatric and adolescent patients who underwent MAT were older and more likely to be female and have private insurance than those undergoing meniscal repair or meniscectomy. MAT was only performed in 17 of 47 children's hospitals that perform meniscal surgery. These trends highlight the need for further research, especially regarding differences along the lines of sex and insurance status.

Social Media Utilization Trends in Orthopaedic Surgery Residency Programs During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has changed the way orthopaedics programs are educating and recruiting residents and applicants. With an increased focus on online and virtual programming, there has been an uptick in social media usage by orthopaedics residencies as a means of communicating with applicants. This study investigated the growth in utilization of social media platforms by residency programs since the beginning of the COVID-19 pandemic. METHODS: Instagram and Twitter were queried for each orthopaedic surgery residency program. It was determined if each program with a corresponding social media account was created before or after March 1, 2020. The number of posts per month were tabulated for accounts that existed prior to March 1, 2020. RESULTS: 187 orthopaedic surgery residency programs were identified using the AAMC ERAS database. Of these programs, 74 (41.6%) were found to have an Instagram profile, and 50 (26.7%) were found to have a Twitter page. Of the 74 Instagram profiles, 45 were created after March 1, 2020, representing a 155% increase. Of the 50 Twitter pages, 15 were created after March 1, 2020, representing a 43% increase. Instagram accounts that were active before the pandemic had a 96% increase in the number of posts per month, on average, after March 1, 2020. CONCLUSION: Over one-third of programs are utilizing social media for recruitment purposes. There has been an 155% increase in Instagram and 43% increase in Twitter usage by residency programs since March 1, 2020. Instagram accounts created prior to the pandemic also demonstrated a near doubling of increased utilization after March. This represents a new, cost-effective way to connect with applicants in a time when in-person interactions are limited.Level of Evidence: III.

Neuropathic (Charcot) Arthropathy of the Knee.

Neuropathic arthropathy of the knee (Charcot knee) is a rare pathology defined by progressive destruction of bone and soft tissue in a patient with underlying peripheral neuropathy. Historically, Charcot knee was associated with neurosyphilis, but it has been increasingly described as a late stage of diabetes. The pathophysiology of the disease is not completely understood, but theories include repetitive microtrauma and an abnormal neurovascular response. Patients present with a warm, swollen, and unstable joint and have rapid bone resorption and characteristic findings on pathology. Nonsurgical options for pain and dysfunction include total contact casting and bracing treatment. Pharmacologic management includes diphosphonates, although this use is considered off-label. Surgical management historically included knee fusion. However, recent case series have suggested that newer prostheses allow for successful arthroplasty in this cohort, although complications are higher when compared with joint arthroplasty in patients with normal neurologic function.

Clinical and Radiographic Predictors of Nonunion in Open Tibial Shaft Fractures.

Open fracture is a risk factor for nonunion of diaphyseal tibia fractures. Compared with closed injuries, there is a relative lack of scientific knowledge regarding the healing of open tibia fractures. The objective of this study was to investigate which patient, injury, and surgeon-related factors predict nonunion in open tibial shaft fractures. A cohort of 98 patients with 104 extra-articular open tibial shaft fractures (OTA/AO 41A2-3, 42A-C, and 43A) were treated surgically between 2007 and 2018 at a single level 1 trauma center and were retrospectively reviewed. Patients underwent irrigation and debridement followed by definitive intramedullary nailing or plate fixation. Patient, injury, and perioperative prognostic factors were analyzed as predictors of nonunion based on anteroposterior and lateral radiographs. The nonunion rate was 27.9% (n=29). There were 12 occurrences of deep infection (11.5%). The median follow-up was 14 months. High-energy mechanism of injury (hazard ratio [HR], 5.76), Gustilo-Anderson class IIIA injury (HR, 3.66), postoperative cortical continuity of 0% to 25% (HR, 2.90), early postoperative complication (HR, 4.20), and deep infection (HR, 2.25) were significant predictors of nonunion on univariable analysis (P<.05). On multivariable assessment, only high-energy mechanism of injury, Gustilo-Anderson class IIIA injury, and early postoperative complication reached significance as predictors of nonunion. These data also indicate that lack of cortical continuity is a significant univariable radiographic predictor of nonunion. This is potentially modifiable, may guide surgeons in selecting patients for early bone grafting procedures, and should be assessed carefully in this high-risk population. [Orthopedics. 2021;44(3):142-147.].

Nonoperative Management of Subclavian Artery Thrombosis in Pediatric Clavicle Fractures: A Case Report.

CASE: A 12-year-old patient presented after a fall onto her upper extremity. She was found to have a mildly displaced clavicle fracture with a subclavian artery thrombosis. Given the reconstitution of flow distal to the thrombosis, the patient was treated nonoperatively in consultation with vascular surgery with anticoagulation and a sling for immobilization. CONCLUSION: This case highlights the importance of a thorough neurovascular examination even in a mildly displaced fracture. Nonoperatively managed thromboses may be treated successfully without orthopaedic fixation or vascular intervention, although the natural history of this injury is likely not fully understood.

Risk Reduction and Perioperative Complications in Patients With Diabetes and Multiple Medical Comorbidities Undergoing Charcot Foot Reconstruction.

BACKGROUND: Modern patient safety programs focus on medical optimization of patients prior to surgery, regional anesthesia when possible, and hospitalist-orthopedic co-management during the perioperative period. METHODS: Eighty-five consecutive patients with diabetes and multiple medical comorbidities underwent surgical reconstruction for acquired deformities secondary to Charcot foot arthropathy with circular ring fixation between 2016 and 2019. All patients participated in a standardized risk reduction program that included medical optimization prior to surgery, regional anesthesia whenever possible, and hospitalist-orthopedic co-management during the perioperative period. Charts were retrospectively reviewed for medical comorbidities, complications, and length of stay. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator was used to retrospectively calculate their predicted perioperative risk. RESULTS: On multivariable analysis, longer lengths of stay were associated with low preoperative hemoglobin values (rate ratio [RR], 1.36; P = .01) and congestive heart failure (RR, 1.42; P = .02). There were 22 (26%) complications, though only 10 (12%) were serious. These included acute kidney injury (n = 6), sepsis (n = 2), 1 cardiac event, and 1 pulmonary embolism. Overall, the accuracy of predicting a complication using the ACS NSQIP Risk Calculator was 74% (95% CI, 63%-85%), which was comparable to the accuracy of predicting a complication using only patients' congestive heart failure and pin-tract infection statuses (c = 74%, 95% CI, 62%-86%). DISCUSSION: Medical optimization of patients with diabetes and multiple medical comorbidities prior to elective complex reconstruction orthopedic surgery allows the surgery to be performed with a predictable risk for perioperative complications. Preoperative anemia and congestive heart failure are associated with longer hospitalizations in this patient group. The ACS NSQIP Risk Calculator appears to be a reliable predictor of complications during the perioperative period. This study demonstrates that reconstructive surgery in this complex patient population can be accomplished with a reasonable exposure to perioperative risk. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The effectiveness of the functional movement screen in determining injury risk in tactical occupations.

Injures are common in workers engaged in tactical occupations. Research suggests that the functional movement screen (FMS) may provide practitioners the ability to identify tactical athletes most at risk for injury. However, there exists controversy as to the effectiveness of the FMS as a tool for classifying injury risk. The purpose of the meta-analysis was to determine the predictive value of the FMS in determining injury risk in workers engaged in tactical occupations. We searched MEDLINE, Military and Government Collection (EBSCO), National Institute for Occupational Safety and Health Technical Information Center and PubMed databases for articles published between January 2000 and October 2017 [corrected]. Ten studies met the inclusion criteria. Multiple random-effects model meta-analyses were conducted, with an odds ratio as the effects metric. FMS cut-off score, occupation, injury type and sex were used as moderators for the analyses. The odds of injury were greatest for tactical athletes with FMS scores ≤14. Personnel scoring ≤14 had almost 2 times the odds of injury as compared to those scoring >14. However, the magnitude of the effects were small; thus the relationship between FMS cut scores and injury prediction does not support its use as a sole predictor of injury.

Group B streptococcus septic arthritis of the hip following spontaneous abortion.

Group B streptococcus (GBS) infection of the hip in otherwise healthy adults is a rare entity that is previously only reported following peripartum gynaecological procedure and instrumentation. We report a case of infection of the hip with GBS following spontaneous abortion. Delay in identification of infection as the cause of pain ultimately leads to irreversible joint destruction. This case report will heighten the awareness of the first contact providers as well as orthopaedic surgeons to be more vigilant for possible septic complications associated with gynaecological procedures/complications and subsequent painful joints. To our knowledge, this is the only case report showing association of GBS infection in hip associated with spontaneous abortion.